Episode 51: Hernia Repair Techniques with and without Mesh | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Good evening everyone. Welcome to Hernia Talk Live, our weekly q and a with everything you need to know about hernias and all the different topics that are hernia related. As many of you, my name is Dr. Shirin Towfigh. I am a hernia and laparoscopic surgery specialist. You can follow me at Hernia doc on Twitter and Instagram and at Dr. Towfigh on Facebook. At the end of this Hernia Talk Q&A session, I will post our link to my YouTube channel where you can watch and share it. And today will be an amazing, amazing session because many of you have asked for Dr. Sbayi to come on. I have shared some patient with Dr. Sbayi and he is going to be probably one of few surgeons who can really help you with your need. So I’m very, very happy to welcome Dr. Sam Sbayi. He is a general surgeon and hernia specialist out of New York at Stony Brook. You can follow him at S S B A Y I on Twitter and thank you Dr. Sbayi. Hello.

Speaker 2 (01:15):

Hey, how are you, Shirin?

Speaker 1 (01:17):

Good. Thank you so much for giving us some of your time. I know it’s later in the evening now that it is on my side of the coast. So

Speaker 2 (01:29):

Yeah, the sun is just going down right now, so it’s getting dark right outside now.

Speaker 1 (01:32):

Yeah, we’re a little cloudy, but it’s been unusually chilly for a spring in California lately. But it’s all good. I’m not complaining. Yeah,

Speaker 2 (01:45):

We’re seeing some sun and finally it’s starting to warm up here, so we’re very excited.

Speaker 1 (01:50):

Very good. So many have sent in their questions and it’s going to be kind of a busy hour, but maybe we can start first, Dr. By, let me know. I let our audience know what your practice looks like and kind of give a glimpse of why I actually ask to be one of our guests.

Speaker 2 (02:12):

So I run an emergency general surgery service, which occupies a lot of my time, but I also have a very busy elective practice where I see a lot of hernia patients. And one of the unique things that I do is I do a pure tissue repair, the shouldice repair. So I had a good almost two years at the Shouldice Hospital where I trained and worked before I came back to the US at New York to practice in general surgery.

Speaker 1 (02:43):

And you’re from, are you from Canada?

Speaker 2 (02:45):

Yeah, I was born, born and raised in Toronto.

Speaker 1 (02:47):


Speaker 2 (02:48):

Wow. Shouldice was right in our backyard.

Speaker 1 (02:51):

Yes. So I visited the Shouldice hospital back, I want to say maybe 15 years ago. Mohammed, Dr. Mohammed was there and I got a tour. I got to watch the whole system and watch the operations. It’s definitely very different than any hospital or outpatient experience I’ve ever seen. I loved it. I thought it was really cool. Yeah. So what they told me, and maybe you can kind of give me a little insight, what they told me was, so you have, let’s say 10 or 12 surgeons that offer surgery at the Shouldice. Is that correct? That’s right. And then the head doctor, the chief surgeon randomly scrubs in every so often to kind of audit you, correct. To make sure that you don’t sway from the traditional teachings of Dr. Shouldice in your technique, because surgeons can have a tendency to do that, start making up their own technique. And that’s allowed the clinic to offer a very steady stream of operations that are very similar from surgery surgeon, and therefore it keeps your outcomes very similar too. Does that sound right?

Speaker 2 (04:09):

Yeah. It’s very heavy on routine. They’re heavy on quality control. In fact, they have, what do you call, they’re the employees that work there actually, they’ve been there for several years. So you know, don’t get a turnaround of employees who come and go. Some of them been there for at least 40 years. Yeah, there’s a saying, I mean, for surgeons there that all roads end at Shouldice. So many of them actually, they come in and they sort of specialize in hernias when they’re sort of slowing down their practice. But again, they’re very heavy on the technique itself. Dr. Shouldice himself, the son would actually go through the ORs and check on everything and part of the quality control, the chief of surgery would do the same thing.

Speaker 1 (04:57):

That’s so interesting. And then what shocked me was the first time that I saw was surgery being done without an anesthesiologist kind of freaked me out. But that just shows you how naive you are as a US surgeon as to what happens elsewhere in the world. And you’re highly reliant on local anesthetic and that thing you guys have with the syringe, I thought was the coolest technique ever. Very efficient and works really well.

Speaker 2 (05:28):

As you know, Dr. Towfigh, it’s so refreshing to see a different perspective and to learn from others. So clearly I went in there with a different perspective, but when I saw how they do it and how they’ve been doing it for many years with the results and the backlog of patients, it was incredible. They do the most tissue repairs in the world. They do 7,000 a year. Wow. Each surgeon does at least 700 a year as well. So I, they’re very, it’s amazing. It’s amazing what they do.

Speaker 1 (06:02):

So we have a lot of questions related to that. If you don’t mind, I’ll start going through some of these questions and you can help answer them. So, okay, this is, a patient said, my surgeon told me he will do the Bassini repair. How is that different than the Shouldice repair? So there’s obviously multiple different types of tissue-based inguinal hernia repairs. Can you just briefly let us know?

Speaker 2 (06:28):

Yes. How

Speaker 1 (06:29):

You see the

Speaker 2 (06:29):

Difference, the highlights, basically shouldice is heavily rooted in the Bassini repair. The Bassini repair repairs, a pure tissue repair. It was actually very popular and effective when it came out, but it’s a three line layer repair. It was used, it was done using interrupted sutures, which means individual sutures. So you’re suturing tie, suture tie, suture tie, and you do three layers, the shouldice repair…the two differences was that Dr. Shouldice added a fourth line and he did continuous, which means he took one string and sewed with it two lines, and then two did another one, two lines. And so that’s the biggest difference. And he managed to bring down the recurrence rate from over 20% down to 1%. And that’s been consistent. They can track back to 1945 to today exactly what the recurrence rates each year.

Speaker 1 (07:25):

Now one thing from the shoulder hospital too is that it’s very particular about which patients it offers surgery to. So now you’ve, you’ve had your training and experience in show life, you’ve moved to the United States. We have a very different patient population. I’m sure that our patient population in general is more obese or more overweight than the Canadian population. And so definitely more than what the Shouldice operates on. So how have you integrated the Shouldice into your practice that you now have a population that’s different looking?

Speaker 2 (08:04):

So the success of the shouldice procedure with regards to recurrence rate and chronic pain rate is also important because it’s based on weight, weight against your height, which is the B M I. If you are a B M I of 29 or less, we can predictively quote to you that your recurrence rate in the right hands, somebody who’s trained and has the right volume, that your recurrence rate will be 1% or better. Equally with the chronic pain rate, which is 3%, sorry, 3 in 1000, these, this is data that’s can come out of the Shouldice hospital that they’ve published. So in my practice now, I’ve had to adopt the same practice and I tease my patients out. I know exactly who will succeed with the tissue repair and those who don’t, I offer Mesh repair for them.

Speaker 1 (08:53):

Yeah, we call that the tailored approach where you try and do what’s best for each individual patient and not treat them like a statistic. Exactly. Yeah. I love that. Another question is, is there anything equivalent to the Shouldice for umbilical or peri-umbilical or ventral hernia repairs? Because I actually read summary, some posts on social media and they say, I have umbilical hernia repair. Can you do a Shouldice repair on me. And we have to explain, Shouldice repair is very specifically a repair of inguinal hernia is either indirect or direct, and there’s a modification of it for femoral hernia. So what do you think is equivalent? Is there an equivalent for ventral or Yes.

Speaker 2 (09:39):

Yeah. Yeah. So not only did they practice inguinal hernia repairs, but they did also abdominal wall hernias with require with the same tailored approach. So if you fit the mold so to speak, you would be successful with that. And the approach was a sutured repair, two or three lines or even four lines depending on the surgeon. But it would be a repair like the Mayo repair, which was sutured, yes. But it’s a horizontal mattress suture and it’s running and it’s reinforced by second line. So you’re not just sewing tie, sewing tie, but you’re running a whole line and then reinforced it with a second line. And that has been very successful for, according to Dr. Michael Alexander, who’s since retired, he’s done over 2000 with zero recurrences.

Speaker 1 (10:26):

Yes, he was great. I misspoke. Dr. Alexander was the sergeant that I connected with at the Shouldice at time. So that’s interesting. Do you think that the multi multilayer repair in essence, because just to clarify, what kind of suture were they using for the groin?

Speaker 2 (10:49):

Stainless steel.

Speaker 1 (10:50):

And what about for the abdomen? Same.

Speaker 2 (10:52):

Really same. And their back, the back fall, they fall back onto a prolene, fall

Speaker 1 (10:58):

Back onto, yeah. And in your practice, what do you use?

Speaker 2 (11:02):

I actually, I have had a lot of patients ask me, do you use the same suture? So I managed to find out the distributor and it’s actually here in Garden City. So I get stainless steel, it comes on a spool when little details, it comes on a spool and you have to biting needle separately. So you cut 23 inches. Yes. You wedge it onto the needle and you sterilize it.

Speaker 1 (11:25):

Yeah. Well, so in the back room at the Shouldice, there are women and they’re only women that are doing that. They’re making individual sutures for the searches. I saw that. That was really cool.

Speaker 2 (11:35):

Yes. Well, I mean there’s definitely men and women there, but they’ll also do the same thing for the local anesthetic. They used to use amide, sorry. And it would come in these big bottles. They’d measure it out, put it on the scale, mix it and then sterilize it. But they’ve moved on to a virgin at Bupivocaine right now. So that’s what they’re using iv.

Speaker 1 (11:58):

Very cool. And then, so my question is, do you think in some ways by doing multiple layers of sutures over and over again, you’re kind of mimicking Mesh in that you’re just making your own quote Mesh? I’m using that term very loosely. And so that kind of layered approach is, so the layered approach does two things. It’s like doing a diastasis closure over a hernia repair. It takes attention off the original repair. Exactly. That’s the first repair from pulling apart. And that’s true for the shoulders too, which is great. But in some ways I feel that if you’re doing a lot, you’re actually kind of mimicking the Mesh. Cause you’re putting in permanent something either prolene or steel as your scaffold. Right.

Speaker 2 (12:57):

That’s exactly what it is. Dr. Alexander May have told you this, but whenever he spoke about it, it’s exact like putting rebar. Yes. And then you’re creating a scaffold for the body to actually create the linkages, the collagen fibers and the scar tissue. That is actually the glue for the repair. So the stitch is actually just a scaffold. That’s all we’re doing. Our job is just to put it together. It’ll stay there long enough until that collagen falls into place.

Speaker 1 (13:25):

Great. Another question is for a patient with a small indirect inguinal hernia and a B M I of 27, so overweight but not obese, would the Shouldice still offer better long-term non recurrence than the Bassini and even meshed by a good surgeon is hard to be, be 1% recurrence. Is Shouldice considered your gold standard

Speaker 2 (13:50):

For the right size patient? So again, it’s tailored. It has to be tailored. If you go over that, you run the risk of getting a higher recurrence rate. And that’s where all the data or success of data out of the Shouldice hospital is. They haven’t really done an on heavier patients from different size groups. So that I’m kind of hesitant to move up in the weight, but certainly I do emergencies as well. So there were circumstances where I could not use Mesh and so I did a suture technique. But of course you have to tell a patient there is a risk for a higher recurrence rate

Speaker 1 (14:24):

And B M I of 25 to 30 is concerned over overweight. So would you do a Shouldice in a B M I of 25 to 30?

Speaker 2 (14:35):

Yes. I mean, so there’s flexibility. And recently there was flexibility at the Shouldice Hospital for a few pounds. So according to the chart, it might take you up to 30 or 31 with BMI. So, but I don’t think I have the courage to go higher that for a shouldice repair.

Speaker 1 (14:53):

And do you believe, yeah. Do you believe shouldice is superior to the Bassini?

Speaker 2 (15:02):

I don’t practice the Bassini. I’ve done it a handful of times. I mean, my experience in my expertise is in the shoal ice repair. So in my hands it’s definitely superior.

Speaker 1 (15:12):

Okay. Yeah, that’s a great answer. When I do the tissue repair, sometimes I feel that there’s not enough tissue for a Shouldice, and I feel that a Bassini maybe less put less tension. Do you think there’s any validity to that?

Speaker 2 (15:34):

It all depends on how it feels. So if you feel like there’s tension, there’s always an opportunity to do a muscle relaxing incision as well, which would provide you some tissue to bring over as well. But again, there’s always an opportunity to use Mesh and I found it very important to discuss this upfront with patients. And a lot of them will tell you actually what happens if you fall into that situation where you might have to use Mesh? What do you do? They end up telling me, well, just close me whichever way you think, don’t use Mesh. Or some will say, okay, use Mesh. Just fix me. Right.

Speaker 1 (16:09):

Yeah, yeah. And then what do you think about direct versus indirect? We’ve had this come up multiple times on hernia attack. Most of the tissue repairs are ideal for indirect hernias. The muscle is much more mobile in that region. As you get more medial towards the bone, there’s not that much mobility of the muscle. So how do you feel about doing tissue repairs for direct inguinal hernias?

Speaker 2 (16:37):

Very comfortable. Again, I have to tailor it, but once you get into the recurrences, that’s where you don’t get the flexibility and the pliability of the tissue. And that’s where the muscle release is important. And that’s where if you may have to consider Mesh at the same time there.

Speaker 1 (16:54):

Yeah. Question, does the increased amount of suture material increase the risk of foreign body reaction? Have you seen that?

Speaker 2 (17:02):

No, I have not. I have not. But what I am learning from my patients is that there are many who have environmental allergies. So there are elements in the stainless steel and their percentages of it, if you look it up, the exact steel that they use at the shore ice hospital, it’s the same one I use. It’s three Three, sorry, three L. Look it up. It’ll tell you the exact percentage of the elements in it. It could be nickel. Maybe you’re allergic to nickel, it may not fit you, so prolene might be a good option for you.

Speaker 1 (17:33):

Does it have nickel?

Speaker 2 (17:35):

It does.

Speaker 1 (17:35):

Oh, okay.

Speaker 2 (17:36):

It’s like in the single digits.

Speaker 1 (17:39):

I had a patient who had something called pelvic congestion syndrome. So that’s one uncommon reason for pelvic. And the treatment for this is to basically cut out the ovarian vein or destroy the ovarian vein as part of the feeding this kind of varicose veins situation in the pelvis. So she had coils of this, but they’re different types of brands of coils. Unfortunately, this brand of coral had nickel in it, and she had a pretty bad nickel allergy, so she didn’t know. So she had both ovarian veins coiled and it basically gave her a burn of her and very severe pain didn’t go away. And we went in and surgically excise ovarian vein on both sides and that cured her. But you know, just don’t know. Sometimes when you put implants, even things like coils that the interventional radiologist did, if you have side effects from it.

Speaker 2 (18:44):

Well, we learn a lot from our patients. I have patients who request samples and we send the samples out to them and they test them. Yeah. I had a patient last week who came in with a 20 page study out of a chemical area that actually tested stuff for everything. Yes. I recently had somebody who was allergic to manganese. There’s a small percentage of manganese in steel and she, her pain would not go away. And we ended up removing the steel. Yes. And replacing it with prolene. And thankfully she’s doing a bit better now.

Speaker 1 (19:15):

But I have a lot of patients that I see for Mesh reactions. Asia syndrome is another term used for it. And it’s basically a reaction to the implant and it’s a systemic autoimmune or inflammatory reaction. And I’ve had two that had reactions to actual suture to the point where I had to go in and remove the suture and use absorbable suture in them, or I have put the suture, I just removed it and just let everything else stay. And they haven’t had a recurrence in, but it was since. But I try and push the surgery as far out from the original surgery as possible to kind of encourage the patient’s own healing. But that is important. Yeah. Happens.

Speaker 2 (19:57):

That’s important. The Vicryl, the antibacterial Vicryl has got something called an, I think it’s tinsel and I had to use Chromic [inaudible] instead. So wow. That I totally taught me something new, this patient. And then how far out should you operate on somebody who has a recurrence? The shouldice hospital has a strict guide there. You don’t operate on anybody unless it’s after 12 months.

Speaker 1 (20:21):

Oh wow.

Speaker 2 (20:22):

Until everything settles down. And of course, as you know, I mean at being at the academic centers, sometimes you can’t wait that long just because people present with a lot more symptoms. So I mean, it’s a tough decision. You want to do the right thing for your patient.

Speaker 1 (20:36):

I think that 12 month number came because the studies show that as you look at patients with chronic pain, the numbers decrease at the far the out you go. So many of those people that present with chronic pain, which by definition was any pain or symptoms, after three months, they got better and almost cured by 12 months. But I mean, if you have a meshoma or a hernia recurrence, that pain’s not going to go away in 12 months. So that’s true to kind of understand how to specifically evaluate patients too and not have a blanket thing. Okay. Another question about B M I. What is your opinion about the Marcy repair for males and females and then this is a 30 year old healthy male with a low B M I 21 or 22 that’s calling.

Speaker 2 (21:24):

So the I Marcy repair is also multiple suture layer repair. I have not done any of that, so I am not a person to comment on that. Unfortunately.

Speaker 1 (21:35):

I have a book and there’s like a hundred different tissue repairs. Everything has a little tweak. It’s like buying a shirt or tennis shoes. There’s like a million different ways. They all have the same function. So Mark,

Speaker 2 (21:48):

Yeah, there’s a Dr. Abraham in Israel actually, who’s done, I think done quite a bit of this on his patients fertile females where they had umbilical hernias. And there’s always a question in our communities about when to operate on a female who’s sort of planning to conceive. But I think if you look him up, you might find some stuff on him that he’s actually written quite a bit on it.

Speaker 1 (22:13):

Yes. So for inguinal hernias and Marcy repair, just a simple closure of the internal ring. It’s not considered standard for males. It is considered appropriate for females with small inguinal hernias. And so that’s kind of my answer for your question there. Next question is, if I were scheduled for an open non Mesh hernia repair, inguinal hernia repair just on one side and my surgeon suspects I may also have a similar hernia on the other side, what would you recommend I do and what questions should I ask them? That’s a good question.

Speaker 2 (22:55):

Very good question. So it depends on what they’re doing. If they’re doing a laparoscopic approach, they have the unique luxury of actually seeing both sides and addressing both sides through the same incisions. If they’re doing an open, you’re going to require another incision.

Speaker 1 (23:09):

Yeah. That’s the downside with the open is you only an, you can only see what you’re looking at and can’t see elsewhere. That’s correct. So I will answer this as if you have a hernia that it has that’s symptomatic so you have pain from it, or you have any symptoms where people think it’s from a hernia and it’s on both sides, then a laparoscopic approach is the best approach because you can treat both sides. If you don’t want a laparoscopic approach or don’t want Mesh, you only want open repair without Mesh, then you’re stuck with just one side. And I would use imaging to confirm if you have a hernia on the other side, it would be inappropriate to make a scar just to look and see, be okay if you have a hernia. Yeah. So imaging would be number one. And then if you have no symptoms and they just happen to find a hernia on the other side, there’s no urgency to repair that side if you have no symptoms. Okay. Well someone just says, good evening, I’m glad that you have this talk. I’m right now finally getting some answers. I’m from Bend, Oregon and finally got my diagnosis from two different doctors in New York. So I think that’s great. More thank yous for the great discussion. What is the difference between prolene and Ethibond suture and also Orthocord? I haven’t heard of Orthocord that maybe is an orthopedic thing. Is that A is orthocord.

Speaker 2 (24:38):

I’m telling you, we learn so much from our patients. These are such good questions.

Speaker 1 (24:42):

You love it. My patients are the best. The heart talk patients, they’re respectful, they’re lovely, and they’re so knowledgeable. Okay, so ortho code, sorry, ortho cord is part P D S monofilament and part something else. That’s interesting. It’s, it’s P D S looks like

Speaker 2 (25:17):

PDS absorbable.

Speaker 1 (25:19):

Yeah. P. So PDS, it’s a great suture. It’s technically absorbable suture. Oh, it’s a combination of PDS and I think wire. Yeah, it’s wire plus P D S. That’s interesting. Why would you do that? Unique proprietary material provides a supple solution for soft tissue while retaining its strength and not security in or Okay. An orthopedic. So, okay, so ortho cord is wire, which is what orthopedic surgeons often use, but they integrated absorbable suture in it to reduce how much total wire you need. So you get early tensile strength, but less overall suture at the end. We don’t use orthocord by definitions. Orthopedic. Okay. Difference between prolene ethibond. Would you like to answer that

Speaker 2 (26:17):

Prolene and ethibond

Speaker 1 (26:19):

Or I guess it should be

Speaker 2 (26:21):


Speaker 1 (26:22):


Speaker 2 (26:25):

So I think ethibond is more, I’m, I’m going to ask words. Braided

Speaker 1 (26:31):

Ethibond is braided

Speaker 2 (26:32):

Poly. Yeah, it’s braided. So okay. So the difference between braided probably and monofilament. Yeah. So interesting story with shouldice repairs. They used to use permanent stitch always. So they started out with silk, which was a braided suture, and that created some infected sinuses. So I think unfortunately, I think the braided, I don’t know, I may be at risk at that, but that’s what a braided is. Monofilament is more slippery and I think it creates less reaction to the tissues as well. Right.

Speaker 1 (27:02):

Yeah. And then one’s polypropylene. Ones polyester. In my practice, I would say that the beauty of the braided polyester is it’s very soft. So if it’s a thin patient and you want kind of close to the skin, like a belly button hernia, I tend to use the ethibond, did I say? Because you don’t feel that tips that you cut. But prolene, like you said, it’s also permanent, but it’s monofilament. It’s more like fishing wire. So it’s it, it’s nice and flat, it goes to the tissue. Much nicer, less risk of infection. But we have various options for permanent tissues surgery. Okay. Oh, this one I have. Okay, here’s another question. At the Shouldice clinic, I’m going to show this to you real quick. At the Shouldice clinic, they told me they will cut my creamer muscle. Why is that? And do you cut the cream hysteric muscle?

Speaker 2 (28:10):

Very good question. They cut the cremasteric muscle. Yes. And they found that it actually decreases recurrence rates. But the downside of that is that you lose your cremasteric reflex, which means if you jump into the lake, your testicles don’t move up into your body, into the cold water. But there’s also, most of the time you’ll have a nerve that runs in the cremasteric muscle, which is called the genital branch of the genital femoral nerve. So it’s going to transect that. And from my experience and the shouldice experience, you’d think you’re going to lose some sensation. You’re absolutely right. You’re going to lose sensation temporarily. You’ll be numb there. But we found that somewhere between six months and 24 months, everybody gets their sensation back and there’s loss, there’s no loss of motor function. Very important question as well. Everybody wants that. Yeah.

Speaker 1 (29:03):

So the testicle doesn’t complete drop, the scrotum doesn’t completely drop.

Speaker 2 (29:09):

No. There are tissues that are closer to the testicle that’ll hold it up there. So it’s not just the hysteric, that’s just, I think it’s mostly just for the reflex.

Speaker 1 (29:18):

And though they cut the cremasteric muscle, they do hitch it up against the pubic bone,

Speaker 2 (29:23):

Right? Yeah. It is reattached to the closure of the external bleak at the end. No,

Speaker 1 (29:29):

Yeah, I remember that.

Speaker 2 (29:30):

And the proximal one, the one that’s closer to where the cord drops into the belly, that one swung across around the spermatic cord like a scarf. And that’s the beginning of the recreation of that deep ring.

Speaker 1 (29:44):

Yeah. Yeah, that’s true.

Speaker 2 (29:48):

Try not to be too technical.

Speaker 1 (29:51):

Some of the questions that are asked I really love mean look at all these cream hysteric muscle questions. This patient had an open angle hernia pair with a plug-in patch for a direct hernia. So that’s a type of Mesh. I now have chronic testicular pain unchanged from prior to surgery. Many surgeons do not. No, many surgeons want to do Mesh removal, triple neurectomy and laparoscopic Mesh repair of the recurrent hernia. Why can’t I just have a tissue repair?

Speaker 2 (30:21):

So I get these patients as well. Yeah. Come specifically for a tissue repair. And again, my selection criteria is the same. It’s got to be tailored and it’s according to the weight. So if you fit the BMI, I’m happy to do it. These tend to have a lot of scar tissue. It’s technically challenging to remove and release this spermatic cord as well. Yeah, there is some success, Ashley, in repairing it using the shouldice repair. But again, the key is sort of properly releasing the tissues there. And again, the triple neurectomy is important because you’re suffering from chronic pain. So you need somebody who knows where these nerves are and to address them properly. Laparoscopic is a good option as well. I mean they’re, Dr. Chen, I believe he has, he had a great talk about doing the triple within the belly and just following the nerve up there and clipping them there. But I would definitely do a triple neurectomy when I do this.

Speaker 1 (31:19):

So I’m more on the selective. So I started doing laparoscopic triple. We were the second, I think it was first discussed I think in Belgium maybe like 10 years prior. No really did much of it. And then we were the first to present our data and technique and at stages. And I stopped doing it. And I’ll tell you why. The laparoscopic triple neurectomy and I discussed it with Dr Arm. He’s like, you should call it the radical neurectomy because you basically cut the entire length of the nerve. It’s pretty radical. And the reason why I say that is we don’t know this. And I’ve looked at every single anatomy book since then. There’s no anatomy book that tells you that the ilio inguinal or hypogastric nerve has any motor nerve fibers. But it does and it does as it comes off the spine before it pierces the lateral abdominal wall to come to the front of the muscle, the anterior do wall, there’s a lot of muscle fibers and motor fibers that it releases.

Speaker 1 (32:28):

So in some patients, or if you do this laparoscopic triple neurectomy, you’re actually denervating that abdominal wall and you get this asymmetric bulging of that side. I think a horrible complication. There’s nothing you can do about it unless you do some very radical kind of plication surgery. It doesn’t get better and it’s just not a pleasant way to do this. Subsequent to our experience, Dr. Chen presented at the Pacific Coast Surgical Association, his much larger series, and I approached him after his presentation. I said, I’ve been experiencing these denervation problems. You didn’t mention it in your study. And the paper got published. And he said, I asked him if he sees it. He’s like, yeah, I see it, but they get better. And that has not been my experience. Interesting. And I’m a huge not advocate of triple neurectomy. The reason why triple neurectomy became popular was with Dr.

Speaker 1 (33:41):

Amid. He had patient after patient, after patient, like this gentleman that had a plug-in patch repair that had chronic pain. And he found, he looked at his data, triple neurectomy versus not triple. And he found that the patients that had triple neurectomy had better chronic pain, better it better address their chronic pain. However, I’m the skeptic. I think the reason why the triple neurectomy patients got better relief than the non triple is if you could cut everyone at, how should I say this? If everyone’s nerve gets cut, then everyone’s going to have the pain free. Of course it’s not a procedure without risk. There’s risk for neuro and all that. But whereas if you try and be a little bit more sophisticated and figure out which nerves you need to cut and don’t cut the nerves that you don’t, they’re not involved, then potentially you’re saving some people from degradation and some people from neuroma risks. So I spend a little bit more extra time to try and figure out what nerves need to be addressed. And I try very hard not to do anything laparoscopically with regard to direct. If I do, then I get the nerve way as disable as I can laparoscopically to really minimize the motor motor.

Speaker 2 (35:16):

That is so interesting because that makes me feel better because I do it on anterior abdominal wall and the open approach. Yes. And then our experience at the show ice hospital has always that I, I’m afraid to say a hundred percent, but I definitely, the majority have gotten their sensation back but have not appreciated this asymmetric bulging of the abdominal wall. But again, something has to be said about being a little bit sophisticated about the way you look at patients. Yes, they are human beings. You have to consider it all their symptoms that they come with. You have to listen carefully to what they’re saying because there’s a lot in there to be said about which way to approach.

Speaker 1 (35:55):

So Dr. Bruce Ramshaw, he was one of my first set of guests on Hernia Talk Live. And I’ll tell you the, it’s great talking to him every time because he really understands how every patient’s different and we’re not God and we don’t understand everything. And we talked about triple neurectomy and selected neurectomy, and what he was saying was that our, and he’s very right because I’ve experienced it, medical practice, especially in the United States, it’s very volume oriented. The more patients you see, the more money you make, the more patients you see, the happier your hospital is with you, the more likely you are to keep your job. Basically. A lot of surgeons are based on volume and RV, which is basically work units that are assigned. So if you do like a brain surgery, that work unit is more than a hernia surgery. So because of that, you don’t have the time to sit down with patients with chronic pain and really figure out which nerve, what symptoms, how is exacerbated, do a nerve block, see how that respond.

Speaker 1 (37:18):

That takes a lot of time and energy back and forth with patients. And when my practice got busy, I saw that I couldn’t do that anymore. I couldn’t be in a system that promoted volume. When I’m seeing more and more chronic pain patients, now I have a luxury of sitting for an hour or more and calling patients and following through with things which I couldn’t do in the prior system. And I think the problem is there’s very few of us that do that. Most patients fall in the crack of institutions that have very well-meaning, very talented surgeons, but they just don’t have, if you have 10 or 15 minutes to see a consult, there’s no way you can really appropriately that’s difficult, be a chronic pain patient. So everyone gets a triple neurectomy, you know what I mean?

Speaker 2 (38:17):

I think I completely hear what you’re saying. I enjoy hearing that it has to be a sophisticated approach. And I think I’m totally for that. But again, when you’re dealing with a recurrent and a recurrent and it maybe a triple recurrent, the chances are that the nerves are really intact there.

Speaker 1 (38:35):

Probably agree. Yeah.

Speaker 2 (38:37):

So I mean, as you’re cleaning up the tissue, developing your planes so that you can sew things together, yeah, it’s a tough decision to make. But like you said, there’s few people who actually take the time to sit and listen to these patients because they may be bouncing from one surgeon to the next.

Speaker 1 (38:56):

Yeah. And they really do need that. And I feel that instead of the patients, instead of going from see five surgeons all within their network with a $20 copay, none of whom can help them. Sometimes you have to save your money, for the one surgeon who will give you the time and effort and get you to the point that you need to go to. It’s just a different way of thinking about medicine. And in the US our medical system is not meant to encourage that.

Speaker 2 (39:25):

I agree.

Speaker 1 (39:27):

So going back to this patient, they want to do a Mesh removal, triple neurectomy, laparoscopic Mesh repair. So your answer was yes, absolutely. This patient can have the plug and patch removed if that’s the cause of their pain and get a tissue repair.

Speaker 2 (39:44):

I just did one last week.

Speaker 1 (39:46):

That’s a

Speaker 2 (39:46):

Great answer. It is not a pleasant procedure. It’s very scarred in and you have to really appreciate the tissues that are running through that space and try to preserve them as much as possible. The Mesh is definitely the cause of this. When I see these patients, everything’s pretty much socked into the Mesh and that’s not a setup for anything. That’s good. So it effort has to be taken to remove the Mesh. And then like I said, in my experience, even if I say I’m going to do a triple neurectomy, I do look for those nerves. Yes. How many times have I found the ilio inguinal nerve intact, especially in a recurrence, and you might see some leftover cremasterics. I definitely take that because I know the genital femoris nerve is the genital branch of a genital femoral nerve is running through there, and usually the ilio hypogastric will dip into the conjoin tendon or the triple layer there. Sometimes you might see it and sometimes you may not, but if you go far medially, you actually could probably find it.

Speaker 1 (40:52):

Yes, yes,

Speaker 2 (40:54):

Yes. My answer is triple neurectomy in these recurrence

Speaker 1 (40:57):

Recurrences. And do you have any problem doing tissue repair after Mesh removal?

Speaker 2 (41:05):

It could get a little bit dicey after the second or third recurrence. So those are talks that I have upfront and I say, listen, I might have to do a Mesh repair. Again, you have to take into consideration, you got to do probably a muscle release as well just to encourage it. But it can be done. I have done it here.

Speaker 1 (41:24):

So I think these are very pleasant operations. I find mushroom removal very satisfying, especially the plugs. And depending on the reason why the patient has symptoms, you sometimes only need to remove the plug, which you can do laparoscopically or robotically and not have to address the Onlay patch part of it. That’s where kind of the tailored approach comes into play. And that way you don’t have to address any of the nerves, especially if they don’t have any true nerve problems. I tell the patient, the process of removing Mesh alone may injure nerves, and that’s why you may need a neurectomy for that process then. So if you don’t have nerve, if this is, how do I explain this? If this is an isolated testicular pain due to the plug, then shaving the plug off of the testicle, the spermatic cord alone should do it. You may not even need another hernia repair if you have your Onlay patch still in place. So the short answer is there’s a lot of options. Open, laparoscopic, robotic, partial Mesh removal, full Mesh removal, no neurectomy and all depends on everything else in that kind of,

Speaker 2 (42:38):

I found many of these patients are so knowledgeable, they come in prepared having read a lot. Yes. So be ready to have a good discussion. Yes. Yeah.

Speaker 1 (42:48):

All right. Next question. I had an abdominal repair in 2018 and hip surgery in 2020, but I have some nerve pain and pubic synthesis pain that doesn’t want to go away. So abdominal repair 2018, all problems that started from an injury in December, 2016. I don’t understand why there’s nerve pain from abdominal repair.

Speaker 2 (43:13):

Maybe the rectus.

Speaker 1 (43:14):

Okay. I don’t know what, if you want to give me more details on that, we’ll try to answer that. But I don’t understand the question because an abdominal repair doesn’t mean anything. Does that mean inguinal repair abdominal approach or an abdominal wall hernia repair. All right. Next question. If I were a healthy patient who didn’t want polypropylene Mesh, could I request a biological or absorbable Mesh so that I could still get this laparoscopically, even though it’s normally used in patients such as with infections? Do you ever use biologics?

Speaker 2 (43:52):

N no. Not in laparoscopic, but it is, there’s a lot more data coming out about the recurrence rates with them and they seem to be improving, but the numbers that they’re reporting about is not very high, but they’re thicker. I think they’re thicker meshes and that’s why they may do a little bit better. They’re not thin. I dunno what your experience

Speaker 1 (44:13):

Was. Yeah, so I was part of that initial wave of biologics being the best thing in the world. Interesting. Early two thousands. Yeah. Well,

Speaker 2 (44:22):

I’m so sorry I’m talking to you. I

Speaker 1 (44:23):

Was using it like water and I was at the county at USC, which is a huge burn center. So they already had biologic tissue for skin replacement. And so we had a very cheap contract with the biologic companies. So they were okay with me using these very otherwise very expensive biologic meshes. And I dealt with a lot of Mesh infections and so on. So we learned a lot. We learned that you can’t use biologic Mesh similar to synthetic Mesh. First of all, it’s completely absorbable, so you really want to use it to buttress a good tissue repair. So that’s one way of doing it. And then I really have minimized how much I use biologic Mesh. It’s close to zero right now, unless there’s a infection in the area. Do you have the right to request it? Yes. Is a surgeon able to use it if they choose to, even though it’s not indicated? Yes. What do you know anything about hybrid meshes? I’m becoming a big fan of hybrid meshes. Like

Speaker 2 (45:27):

Tex, it’s ovitex. ovitex is actually, it’s sheep and I think it’s It’s poly biologic.

Speaker 1 (45:35):


Speaker 2 (45:35):

Ovitex. Yeah, ovitex is biologic.

Speaker 1 (45:38):

They have two types of ovitex. They have the permanent

Speaker 2 (45:42):


Speaker 1 (45:43):


Speaker 2 (45:44):

I used that last week too, to bridge on an emergency general surgery patient.

Speaker 1 (45:48):

Yeah. So it’s, yeah, it’s an absorbable biologic similar to stratus, FlexHD, et cetera. It’s, but it’s sheep stomach. But they also have a permanent version. So instead of having sutures through it that are absorbable, they have polypropylene sutures through it. Four polypropylene. Oh, okay. That’s sutures it through.

Speaker 2 (46:10):

That’s the scale. So

Speaker 1 (46:12):

That’s the scaffold. So it’s like 4% synthetic, 96% absorbable. And I feel it has the best of both worlds. So it acts like a biologic and it’s low in inflammatory potential, low risk for reaction and for body reaction and for cessation. But it still has enough synthetic to help reduce your risk of hernia recurrence.

Speaker 2 (46:41):

I’ve had a lot of success with it. I’ve had a lot of questions about doing the tissue repair using biologic by, but in the emergency general surgery world, I use a lot of Mesh. I use phasix, which is biosynthetic and I use ovitex as well. That’s where my experience is, but I don’t, I’ve never really used it to buttress a tissue repair.

Speaker 1 (47:06):

I had a patient who was a, not professional, but very prolific kind of soccer player and he needed Mesh removal. He didn’t want Mesh put back in him, but he had a very large direct hernia. So I did a tissue repair on him and I said, let me put some biologic as a buttress because I don’t want you, if I don’t want you, you to bust open this tissue repair. I he it very well. Excellent. I dunno,

Speaker 2 (47:35):

What did you use?

Speaker 1 (47:39):

I want to say FlexHD.

Speaker 2 (47:41):

Okay, good. Yeah. Good to know.

Speaker 1 (47:45):

Okay, next question. Let’s see. Okay. Someone says, you’re right about the information with this US system of healthcare. It’s better to save and go to a specialist that will have more time.

Speaker 2 (48:02):


Speaker 1 (48:03):

I totally agree. Okay. What’s the best way to diagnose general femoral nerve entrapment? A random question. I mean, entrapment imply

Speaker 2 (48:17):


Speaker 1 (48:18):

You can’t tell if it’s entrapped until you look at it, but you can tell if you have nerve neuralgia like nerve pain. Right.

Speaker 2 (48:26):

So I’ve had an experience with an ilio inguinal nerve that was entrapped and that is painful. Yeah. It follows the exact pathway of where it’s supposed to go.

Speaker 1 (48:36):

Yes, exactly. Again, if you

Speaker 2 (48:37):

Anatomy, yeah, if you do, you know your anatomy, you pretty much know which nerve is involved so you can address it.

Speaker 1 (48:44):

Yeah. Okay. Next question. Can you please ask what steps and or protocols you recommend to reduce surgical site infection Options include chlorhexine shower the night before or morning of surgery. Nasal antiseptics for decolonization of bacteria, warming the patient in the holding area, clipping hair instead of shaving re-dosing of antibiotics using antiseptic coded sutures and using wound warriors. Those are all great.

Speaker 2 (49:19):

Yeah, all

Speaker 1 (49:20):

Close. That’s very thorough. That’s very

Speaker 2 (49:23):

Thorough. Thank you for answering the question.

Speaker 1 (49:26):

I think the antiseptic, the triclose and antiseptic coded sutures have not been shown to be of value, but everything else. Yeah, that’s great. Also, controlled your blood sugars and prefer that you’re not obese

Speaker 2 (49:45):

And you’re not smoking

Speaker 1 (49:46):

And not smoking. Nico nicotine though, right?

Speaker 2 (49:49):


Speaker 1 (49:50):

Marijuana’s. Okay.

Speaker 2 (49:52):

I don’t know. I

Speaker 1 (49:55):

Think, I think

Speaker 2 (49:56):

Absolutely. I know I’m joking. Yeah, definitely. Nicotine is the issue.

Speaker 1 (49:59):

I’m calling you from California. I’m telling you, marijuana seems to be okay for wound healing. It’s the nicotine.

Speaker 2 (50:05):

Good to know, good to know. Some people, nicotine you measure. Do you actually, is that a strict protocol for you? Do you check for nicotine and do you measure it

Speaker 1 (50:14):

For complex security surgery? Yeah, yeah, yeah. And for everything else, I encourage that they reduce it, but I’m not as strict on it for like inguinal hernia.

Speaker 2 (50:25):


Speaker 1 (50:25):

Yeah. Going back to the gentleman with the testicular pain, what are the causes of testicular pain that are not due to the testicle? And I think this is kind of in relation to having had a Mesh. So hernias can cause testicular pain and Mesh injury can cause testicular pain. What are your thoughts on those?

Speaker 2 (50:46):

So interesting, doctor Ben David, before he passed last year, he actually put out a couple of papers. He would actually get transplanted or explanted Mesh from California. Yes. Examined it in at the University of Toronto. And they found that usually somewhere between four and seven years there’s some migration of the Mesh into these tissues. Like the cord? Yes. So the nerve, yeah. Yeah. Into the nerves. They wrote about that. So I, I think that really happens. But for testicular pain, you have to consider the indirect hernias, the direct hernias, which can cause pressure there onto the cord. And then they can actually squeeze whatever’s in that cord. I mean, you’ve got your vas deferens, which is your channel for sperm. You’ve got the vessels as well, and you’ve got some nerves in there as well. So those can all be affected by hernias or by the Mesh that’s migrated into that.

Speaker 1 (51:44):

So testicular pain from indirect inguinal hernias can occur. This gentleman had a direct inguinal hernia, so a direct al hernia, assuming you were correctly diagnosed and you, they didn’t miss an indirect inguinal hernia, assuming that was correctly diagnosed. A direct hernia should not give testicular pain. It’s the indirect inguinal hernias that caused testicular pain repair. That should resolve a testicular pain. You can get a different type of testicular pain if the Mesh is now causing the pain. So that’s kind of where I would say there’s plenty of other reasons for testicular pain. We’ve had two urologists on where we discussed this. I highly recommend you go to my YouTube channel. Look at the episode we had with Dr. Paul Turek about testicular pain. We completely discussed spermatic, varicocele, hydrocele, epididymitis, orchitis, sperm or spermatic, epididymitis, vasal. What’s that one? Osteitis, which is, or Vasitis, which is inflammation and almost like an autoimmune of your Vas. There’s plenty of little things that can cause testicular pain. And you really need to go to a surgeon like Dr. Paul Turek who specialize only in sexual function and fertility in men because they do a lot of testicular pain workups. So I hope that’s helpful for you. We had a great hour with him. Okay. We’re getting very close to our hour. Can you believe that already?

Speaker 2 (53:28):

Amazing. I

Speaker 1 (53:29):

Know. But more questions to come then just keep coming. I had an open right Anglo reconstruction and right abductor, but the burning, I have burning pain in the inguinal hernia in the inguinal area. Yeah. I’ll see. These are difficult questions because burning pain can mean a lot of things. Is it labial? Is it inner thigh? Does it wrap around? Is activity related? These are where you really need to see a specialist. Now how do patients come to see you?

Speaker 2 (54:02):

So that sounds like a sports hernia repair. So if they did a tenotomy as well. Yeah. So I’ve started to see some of these things and you have to know, do a comprehensive workup there, make sure you rule out other stuff. Yeah. But again, like you said, you have to find out exactly more information about what’s going on with what’s the burning from, where is it happening to better identify exactly where the issue is and sort of investigate. I don’t hesitate to investigate with imaging if I need to to find out exactly what’s going on. You might be surprised. You might find a reason for it with the imaging.

Speaker 1 (54:41):

Yeah. It looks like they found a torn extra oblique fibers near the internal ring that was repaired. And then for some reason they’d sacrificed the ilio inguinal nerve. You don’t need to do that. If you have a fascial tear, you just fix the tear and then the nerve pain goes away. And then we published our, we’re publishing our data, but we present it at, we’ll be presenting it at stages as a podium presentation on the downfalls of neurectomy. And we showed a 4%. And I think nationally there’s like a 5% neuroma or recurrent Neuralgia pain. So for example, since you got your ileal nerve cut, like I said, these, every decision that is made has pros and cons. And so neurectomy cons include potential for neuro and more burning pain. So it’s possible that your pain is now from this, there’s a lot of things that can go wrong. You just need a surgeon to kind of sit down and figure it out and maybe get nerve block. Do you do nerve blocks in your office or ultrasound or anything like that?

Speaker 2 (55:53):

I do do trigger injections. Yeah. Yeah. But again, I don’t hesitate to enlist the help of colleagues such as a pain specialist and who can assist me with some of the chronic pain issues.

Speaker 1 (56:07):

Yes. Yes. So you were saying, I assume you see patients both locally and from all around the world. Do you do virtual consultations with them?

Speaker 2 (56:17):

I did a whole afternoon this afternoon.

Speaker 1 (56:21):

You look so fresh though. It’s the lighting,

Speaker 2 (56:25):

You know. You know what it’s like at the academic center.

Speaker 1 (56:29):

Yes, I know. I

Speaker 2 (56:31):

Know. But this is a great way to end my day. This is the best way.

Speaker 1 (56:34):

Oh, well this could be your life. This could be it.

Speaker 2 (56:38):

I Amen. Will be talking.

Speaker 1 (56:41):

Very good. Did you call your office? You have a website? Could they just tweak

Speaker 2 (56:48):

You so they can Twitter account? They can get me on my Twitter handle. You can actually Google my name and profile. You’ll see a complete academic profile there. There’s a hyperlink for shouldice repair. At the end of that, there’s a form that you can fill out PDF and just send it, fax it over to us.

Speaker 1 (57:05):

That’s great. Yeah. And you offer laparoscopic robotic open.

Speaker 2 (57:11):

We part of the division offers all of that. I, I’m getting into robotic right now just because of the complex ventral hernias. Yes. But the bulk of my practice now has been this tissue repair just because it’s a lot. I mean, my clinic has turned into this basically a lot.

Speaker 1 (57:28):

Yeah. Well because there’s a demand, there’s so many patients that we all need to

Speaker 2 (57:31):

Help. And I’m happy to see the complicated ones and sort of sit down and figure it out. I mean, if I don’t have the answer, I’m sure I’ll find somebody who may have a better answer than I do. That’s the one we’re trying to help ’em out.

Speaker 1 (57:42):

How far is Stony Brook from New York City?

Speaker 2 (57:46):

It’s about an hour and 20 minutes.

Speaker 1 (57:48):

By car?

Speaker 2 (57:50):


Speaker 1 (57:50):

Okay. And train.

Speaker 2 (57:51):


Speaker 1 (57:52):

So they can fly in.

Speaker 2 (57:54):

Yep. We get people fly into LaGuardia or J F K or we have ice slip here, which is an airport. It’s about 20 minute drive.

Speaker 1 (58:02):

Great. Well thanks for your time. This was fun.

Speaker 2 (58:05):

Thank you, Dr. Towfigh. This has been a pleasure. Thank you so much.

Speaker 1 (58:09):

Thank you. Hope to see you again soon. Maybe at a conference. I don’t know if you’ll be at

Speaker 2 (58:14):

Las Vegas. We’ll

Speaker 1 (58:16):

Be at stages in Las Vegas.

Speaker 2 (58:17):

I’m going to try and get there.

Speaker 1 (58:19):

I know, yeah. We’ll catch up then there.

Speaker 2 (58:22):

Thank you so much. All

Speaker 1 (58:23):

Right. So lovely. See you. Thank you. We’re going to say goodbye. Thanks everyone for joining me. As you know, we’ll be here again next week doing another episode of Hernia Talk Live. Many of you’re already on hernia talk.com. And so on that note, I’m going to say goodbye. Watch me on my social media accounts for the link to the YouTube video for this hour. And I’ll see you all next week. And thank you, Samer.

Speaker 2 (58:54):

Have a good night

Speaker 1 (58:55):

To talk to you.

Speaker 2 (58:56):